I BOBBED AND WEAVED MY WAY through the crowded waiting area of what we called āthe APES,ā short for the Acute Psychiatric Service, Bostonās busiest walk-in psychiatric clinic. It was just down the hallway from the emergency room of Massachusetts General, the major teaching hospital at Harvard Medical School. Our group of young psychiatric trainees nicknamed it the APES because of its jungle-like ambienceāa perpetual array of troubled souls found their way here, either by their own free will or thanks to the assistance of the local police or emergency technicians.
I was twenty-seven and had finished medical school and a year of internal-medicine internship before leaving my hometown of Los Angeles for Boston. Only six months earlier, I had sold my car and everything else I owned and shown up at my empty one-bedroom Cambridge apartment with three boxes and a duffel bag. I had been anxious about moving and starting a new training program but excited to begin my career in psychiatry. Even though I was Phi Beta Kappa and summa cum laude, I still couldnāt believe I was going to Harvardāalthough part of me thought, if they were letting me in, how good a school could it really be?
As I inched through the cramped waiting room, I almost bumped into a woman with bloodstained white gauze wrapped around her wrists, being escorted by two emergency technicians. I finally made it to the coffee room, where some of the other psych residents were taking a break between patients. There was something about being thrown into this intense environment that created an immediate bond between us. Humor was our favorite coping mechanism, and we constantly tried to one-up one another with jokes and patient horror stories to both shock and impress.
The first year of psychiatry residency combined rotations in emergency settings and inpatient units. In addition to these medically oriented training experiences, we were expected to begin taking on at least three long-term outpatient psychotherapy cases. I felt like I was finally jumping out of the textbook into a whirlwind of clinical experience. At the same time, I was dealing with a plethora of real people and their very real suffering. I found it overwhelming, frightening, and often exhilarating. Although I was energized by the intensity of the work, I was usually exhausted and always relieved when my shift ended.
The next morning was Saturday and I could have slept in, but the sunlight on my face woke me up early. I hadnāt gotten window shades for my apartment yet. My girlfriend, Susan, was still sleeping, so I cuddled up to her for warmthāthe narrow beam of sun didnāt do much to heat the room. January was not my favorite month in Boston. Had Susan not been there, I would have already been huddled by my space heater reading Jung and Freud, looking like the Michelin Man in my three-pound parka and wool cap. Instead I threw the blankets over my head and imagined myself back in Los Angeles, where everybody always pretends itās such a fluke that itās eighty-five degrees in January. I knew that calling the landlord to turn on the steam heat for more than five minutes twice a day was fruitless, so I stayed where I was until Susan, an ICU nurse at Cambridge Hospital, stirred and mumbled that she had a shift that morning and had to go.
Sometimes on the weekends I felt a little homesick. Rather than hunker down and start studying for the day, I decided to run out to get a cappuccino and a croissant at my local coffee joint, where I might bump into Mike Pierce.
After completing his residency the previous year, Mike had started a part-time private practice while remaining half-time at the hospital as an attending physician supervising the residents. He was only three years ahead of me, but seemed to have a decade more experience and knowledge. His edgy humor reminded me of George Carlin, and he used it to teach us and help us deal with the tension that was constantly palpable. Mike was already married and had two young kids. Although he was an attending, we got to be good friends. He usually had Saturday-morning patients at his practice in the Back Bay, so sometimes we met early to get coffee and have a few laughs.
I saw Mike in line reading the Boston Globe sports page, so I cut in. āSkipping out on the twins on Saturday morning? I bet Janey is delighted.ā
Mike laughed. āIām just giving them some special mommy time to bond.ā
āHowās the practice going?ā I asked.
āGreat. Ever since I hung out my shingle, itās been a magnet for every desperate psychopath on the East Coast. Another couple of months and Iāll be an inpatient at Lindemann,ā referring to the nearby psychiatric hospital. We took our coffees and croissants over to a small table by the windows.
āSo whatās up for you today?ā Mike asked.
āIāve got tons to read. Lochton assigned me every psychotherapy manual ever written.ā
āOuch, you got the Loch Ness Monster as a supervisor? Have you picked out your plot at Forest Hills?ā
Dr. Herman Lochton was my first assigned psychotherapy supervisor. He was well known in Harvard psychiatry circles and had edited several popular textbooks. He was also the team psychiatrist for the Boston Celtics, and treated senators and other VIPs who flew their private planes in from the Bahamas for therapy sessions. He had created a reputation for himself as a skilled diagnostician and therapist. When he wasnāt busy telling people about his great accomplishments, he saw patients in his private practice. He volunteered one morning a week to supervise psychiatry residents in order to keep his title as a Harvard clinical professor.
āOkay,ā I said. āHe is a bit of a tyrant, and he does have a touch of narcissism.ā
Mike laughed. āA touch of narcissism? The man thinks that heās personally responsible for the Celtics beating the Suns for the championship in ā76.ā
āYeah, I know, the guyās a little nuts. But I am learning from him.ā
āJust be careful,ā Mike said. āHe knows a lot, but I donāt think heās necessarily the greatest psychotherapy supervisor in the world.ā He took a sip of coffee and asked, āSo what else is happening? How are you doing?ā
āYou know, Mike, itās weird. Iāve had some interesting cases, and Iām getting better at listening and talking with patients, but I still havenāt worked with a psychotherapy patient in long-term treatment yet, and Iām not sure Iāll know what to do.ā
āWhat do you mean?ā Mike asked.
āI keep flashing back to med school,ā I said. āThose first experiences as a real doctorāwhether I was doing a physical or taking out a gallbladderāI felt like I was acting, you know, playing the role of what I imagined a doctor to be. And Iām worried that doing psychotherapy is going to feel the same way.ā
āWelcome to the club. I have my own practice, and I still feel like Iām faking it from time to time. But it does seem like the more experience I get, the less I feel that way.ā Mike finished his coffee and looked at his watch. āI gotta run. Iāve got my multiple personality at eight-thirty. I never know whoās going to show up.ā
The following Tuesday, Lochton was scheduled to lecture at group supervision in the psychotherapy clinic. I was the first resident to arrive and caught him combing his hair while holding a small hand mirror. I didnāt know why he bothered because his hair was so stiff with Brylcreem that it never moved.
I couldnāt resist and said, āYouāre looking very sharp this morning, Dr. Lochton.ā
āGary, you can never look too professional for your patients. It shows respect.ā
As I noticed his shiny black dress shoes, I pulled at my khakis in a feeble attempt to mask the scruffy hiking boots that I wore in the snow. I was thankful that I had at least remembered to wear a tie that day.
A few other residents filed in and took seats in the conference room. Lochton checked his watch and began.
āToday I want to talk about the perfect patient for psychotherapy; we call it the YAVIS. The term stands for young, attractive, verbal, insightful, and wealthyāthe s standing for the dollar sign of course.ā He picked up a piece of chalk and drew a large $ on the board. As he continued on about his ideal patient, I kept thinking he was living in a dream world, because we residents almost never saw a YAVIS. We were used to treating the sociopathic, drug-addicted dropouts who frequented our clinic. Rich, intelligent people solved their problems with experienced private practitioners, not first-year psychiatry residents at bargain-basement prices.
At the end of his lecture, Lochton instructed us to look through the file cabinets lining the walls of the clinic. They contained brief evaluations of patients seeking psychotherapy in the resident clinic. He told us to find a teaching case so we could get started doing real therapy. As soon as he finished, we all raced from the room, practically trampling over one another to get to the file cabinets, knowing how ridiculous it was because we had all been rummaging through those files for weeks looking for a decent case.
Searching the files was futile anyway because the typical folder contained only a patientās basicsāage, marital status, and reason for referral. It seldom had enough information to tell us if we had stumbled upon a YAVIS or not. In fact, if it really was a YAVIS, the evaluating resident would have snagged the patient for himself. The real way to find good psychotherapy patients was through personal referrals or word of mouth, not unlike landing an awesome apartment or being set up on a great blind date.
Despite all that, I still routinely thumbed through those tired files, and after a few weeks, I thought I had found my first YAVIS. Sherry Williams was a housewife in her early thirties who lived in the suburbs. She was a college graduate and had never been arrested or hospitalized in a psych ward. She came to the clinic complaining of chronic anxiety. I knew Lochton would approve. I called her and arranged our first appointment.
The first-year psychiatry residents had to use whatever offices were available in the clinic for the day. I scored an office with a little window, although part of the view was obstructed by a file cabinet. There was a small desk that I kept bashing my knee on and a chair and sofa for patients. It had the bare necessities of a psychotherapy practice, including a telephone with intercom and a box of tissues.
At our first meeting, Sherry Williams entered my office dressed like a teenage girl, wearing tight jeans, sneakers, and braided hair. She sat on the sofa cross-legged, looked up at me, and waited. Clearly, it was my move.
I broke the ice by asking about her drive in from the suburbs. It seemed to relax her and start her talking. āYou know those Boston drivers; they think traffic laws are optional.ā
Not sure what to say next, I ventured, āSo tell me about yourself, Sherry.ā
āWell, Iām married to my college sweetheartāāshe flashed her big diamond ringāāwhoās still gorgeous. We have a brand-new fabulous house with a step-down living room and an incredible deck.ā She went silent again, waiting for me to say something. Okay, I thought, now what would a real therapist ask?
āSo what brings you to the clinic today?ā
She stared at me for a moment and finally said, āI just canāt stop feeling nervous, Doctor.ā
At the word Doctor, I almost giggled. I felt like such a phony.
Thankfully she went on. āThe feeling gets worse when my husband travels, and he travels a lot for work since he got his promotion to regional manager. I feel lonely in that big houseāitās boring. Sometimes I get so edgy that I canāt even handle the housework. The laundry piles up, and nothing gets done.ā
It sounded like her anxiety was so overwhelming that it might be paralyzing her at home. My instincts told me not to discuss her mental paralysis at our first session. Instead, I tried to be supportive and get her to talk more about her feelings. āThe anxiety must be very difficult for you,ā I said in my most empathic voice.
āIt is, Dr. Small. It really is.ā She uncrossed her legs and sat in what seemed to be a slightly seductive pose on the sofa. āI just worry about everythingā¦my husbandās job, the mortgage paymentsāwhich is stupid, because I donāt even know what our mortgage is. Eddie takes care of all the bills.ā She sighed and looked at the file cabinet in front of the little window.
āWhat are you thinking about?ā I asked.
āI donāt understand why I canāt feel happy. All of my friends seem to be happy. I have the biggest house, and my girlfriends are all jealous that I got Eddie, but I canāt seem to have any fun anymore. Whatās wrong with me? Do you think Iām depressed?ā
I didnāt know about that yet. I was just glad she didnāt call me Doctor again.
āWhat do you think is wrong?ā I asked, following Lochtonās advice by avoiding yes/no questions and instead asking open-ended ones that would encourage her to talk.
āI feel emptyā¦Itās like I have a giant hole insideā¦here.ā She wrapped her arms around her chest and rubbed her shoulders in what I could have sworn was a seductive gesture.
As Sherry continued her story, I got the feeling she was holding something back. She told me that she couldnāt have children and both she and Eddie were fine with that. Neither of them was really into kids. But the way she spoke seemed rehearsed, almost as if she knew the answers I wanted to hear. I started to wonder whether she was really just an anxious, bored, possibly depressed housewife who wanted to understand herself better or a sociopath who practiced her story after reading some psychotherapy text.
āTell me about your marriage,ā I said.
āI think I fell in love with Eddie the first time I looked into his dreamy blue eyes. We were both juniors at Boston College, and he was the first-string quarterback. My mother loved him, his family had big money, and he was great in bedā¦at least for the first few years.ā
āSo things have changed between you?ā I asked.
āHe works so hard now that heās too tired for sex. I really miss that, you know?ā She grinned mischievously.
It seemed like she was flirting with me. I had read about seductive patients in textbooks, but to actually experience one was strange and uncomfortable. She was a confusing case, but I did have some ideas about what might be going on. Sherry seemed to focus on appearances and possessionsāher dreamy-eyed husband with the family money, her big new house, and her jealous friends. Perhaps she had a narcissistic personality disorderāa condition wherein the individual pursues superficial pleasures in attempts to fill an underlying emotional emptiness and insecurity. But she could also be depressed because of her husbandās frequent travel. Her flirtatious behavior could also reflect a histrionic personality, typical of people who seek attention through dramatic and emotional behavior.
I needed to know more about her before I could make a diagnosis and plan a therapeutic strategy. I continued to gently a...
